Bioethics Forum Essay

Intersex and Sports: Back to the Same Old Game

If you’re trying to make sense of the “decisions” just made in Miami about sex-typing in sports, and you’re struggling, join the club.

The International Olympic Committee (IOC) presumably tasked the group of expert physicians who just met in Miami with the job of coming up with a fair way to decide who should be allowed to compete as a woman in cases of sex ambiguity. Instead, the group “did not address fairness” according to Dr. Joe Leigh Simpson of Florida International University.

What the group did apparently conclude is this: anomalous sex is always primarily a medical condition, athletes must submit to “treatment” if they want to compete, and expert doctors will play by an “I know it when I see it” approach as these doctors personally decide, on a case-by-case basis, who will and won’t compete.

Some of the statements emerging out of Miami border on the surreal. Maria New, a pediatric endocrinologist who specializes in atypical sex, wants “photographs of athletes [sent] to experts like her. If the expert thinks the athlete might have a sexual-development disorder, the expert would order further testing and suggest treatment.”

Clearly Simpson was right: they didn’t consider fairness.

The Miami proposals make no sense from a sports perspective. Plenty of anomalous conditions give athletes advantages – some men naturally have very high levels of testosterone, or especially efficient oxygen processing. Simpson himself admitted in his interview with The New York Times that some people just have a natural biochemical advantage of one sort or another. But we don’t require “treatment” before those nonintersex athletes are allowed to compete. And we sure as heck don’t decide who will be rigorously tested against biochemical fairness standards by sending around nude photographs of them to special doctors.

The Miami “decision” addresses not at all the reasonable concerns some women athletes have about competing against women who might more logically fit what people think of as the male side of a physiological divide, except insofar as it hints that especially high levels of testosterone and other androgens might be medically forced down in advance of competition.

That, then, raises the apparently unconsidered question of why athletes competing as women would be subject to such androgen-capping, while athletes competing as men are not (unless they dope). If we women naturally make all those same hormones – and we do – why do the guys get to keep all they naturally make, and we don’t?

The statements emerging out of the Miami meeting only make sense if you stop trying to think from a sports fairness perspective, and consider them in the context of the way intersex (anomalous sex) has been treated for decades by doctors like Simpson and New. Although the medical system is now changing in response to powerful criticisms from patients rights groups, the standard has been to treat intersex as something that is a medical disaster in the making which must be quietly “fixed” by specialist doctors who are not interested in having their “standards” open for review.

This explains why doctors like New want to make sure every sex anomaly is treated as a medical problem. In their world, they’re not rewarded for accepting benign variation, but rather for diagnosing and “treating.”

Let’s be clear: It is certainly true that some intersex conditions can signal an underlying medical danger, and all athletes deserve quality medical care. But deciding to yank sports fairness off the table in the name of medicine, and providing no clear rules or logic about sex typing in sports, allows these doctors to try to maintain total control over intersex.

It’s notable that, in their statements, the Miami group called for referral of sexually anomalous individuals to “centers of excellence.” Again, this represents a move at consolidation of power. What makes a center “excellent” for intersex care is no more transparent than how doctors at such centers will rule on athletes’ bodies.

Finally, note how physicians seem to insist that their “treatments” are in the best interests of athletes, such that athletes must be essentially be coerced into “treatment” if they wish to play. Again, this aligns with the way intersex has historically been treated in the general populace, with doctors’ insistence, without good evidence, that “normalization” of sex is necessary for patients’ own good.

Parents have until recently been lead to believe that highly invasive procedures, which carry substantial risk, are the only way to “play the game.” Some parents have even reported that their children’s doctors have threatened them with court orders when they’ve chosen to let their sons and daughters keep their healthy but atypical-looking genitalia, so that the children can decide for themselves whether to risk elective surgeries.

Obviously the doctors issuing these problematic “decisions” out of Miami are not bad people. They are simply too used to operating in a paternalistic, nontransparent fashion that prevents any benefit they might obtain from external review.

Although Caster Semenya never meant to become the public face of intersex, I had hoped her case would lead to an improved situation for intersex people – that it would lead to widespread acceptance of the realities of sex variation and of individual rights for people with sex anomalies. Instead, the IOC’s chosen medical advisors seem determined to continue consolidating power over intersex individuals in the hands of doctors who apparently won’t even reveal to us on what they’re basing their rules.

The one glimmer of hope I see out of Miami is the hint that perhaps the IOC will decide to let all those women who were raised as girls simply play as women. Though this might feel unfair to some, it would align with other realms of sport where we accept that some athletes just come with natural biochemical advantages. Moreover, it would remove the veil of fear from families all over the world who continue to wonder whether the new rules will signal true acceptance of their young daughters.

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Hastings Bioethics Forum essays are the opinions of the authors, not of The Hastings Center.

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